Older Adults: Cogmed and Beyond – Questions and Answers

Can you speak to the instance for those with existing ADD and issues related to Alzheimer’s disease (AD)?

Lee Hyer: ADD brain issues are similar to those of the normal aging brain, as was noted in the slides. Beyond that, this is a fuzzy area and one in need of clarification. In fact there may only be one study in this area and it suggests the obvious — ADD increases AD problems. We do not know if it is a predictor. Also, we know that depression and ADD increase problems in general so that may be another factor — the role of depression.

If the ADD brain looks like the normal aging brain, is it likely that the decline would be worse for aging adults with ADD?

Lee Hyer: This is a good question and one still to be answered in research. ADD is probably a predictor of any issues that relate to WM or EF at late life. As such, it is likely a problem for older adults at risk for AD.

Does the decline in activities of daily living (ADL’s) indicate biomarker for AD?

Lee Hyer: No, it is a functional marker that is titrated to brain issues (PET, PIB-PET, MRI). The inter-correlation between IADLs and MMSE is .61 but if you take the more severe patients out, it is reduced by quite a lot. Forty percent of the variance, however, is shared between function and cognitive marker. David Lowenstein should be read here as he advocates for this, as does Don Royal.

Case Example: A 57 year old woman with a long history of depression recently went on Cymbalta. She feels that the medication worked, but that it had a ceiling effect. When she did Cogmed, it seemed to her that the ceiling lifted and she was able to experience enthusiasm and excitement again. She wonders if she was “just imagining” these feelings or if there is an effect of working memory training on dopamine production?

Lee Hyer: I do not know the answer to this, but you raise a good point. Cymbalta is an SNRI and has effects or serotonin as well as dopamine. It is also useful for pain. We just finished a study on this, but what resulted in the mood lifting, I submit, is that Cogmed a) made her a better antidepressant responder, b) improved her mood by itself (no Cymbalta effect) , or c) just made her current situation more evident since she was already feeling better.

Cogmed: There is some evidence that Cogmed Working Memory Training impacts dopaminergic transmission. In a 2009 article published in Science, McNab et al. found that Cogmed training effects were related to decreased dopamine D1 receptor binding potential. Such changes in binding potential impact the availability of dopamine and are associated with changes in the density of cortical dopamine D1 receptors. Two other studies by Brehmer et al. (2009) and Bellander et al. (2011) investigated how individual variations in the DAT1 and LMX1A genes respectively impacted working memory training related gains. For more information on these studies, please click here.

Case Example: A 75 year old retired psychologist living in a multi-level service community has been treated for ADHD for the last 21 years and wonders how Cogmed might work in his/her community?

Lee Hyer:Two issues – one is the question of ADHD above. I believe that Cogmed will be as good with older adults who have ADD (or ADHD) as it is with adults in general. He/she is healthy, I assume. The other question is its use in a CCRC where he/she is located. Again, our data suggest that Cogmed would help AND other cognitive interventions (sham) would probably assist as well, but not to the same extent.

Cogmed: There is increasing evidence that Cogmed is a feasible and effective intervention for both younger and older adults. A study recently published in Frontiers in Human Neuroscience investigated the impact of Cogmed on typically functioning younger and older adults in a randomized, placebo-controlled, double-blinded study. Adults who did adaptive training significantly improved on trained and non-trained measures of working memory, sustained attention (Paced Auditory Serial Addition Task; PASAT) and self report of cognitive failures (Cognitive Failures Questionnaire; CFQ) compared to the placebo control group (Brehmer et al., 2012). For more information on published Cogmed studies, click here.

Does the routine use of vitamins improve cognitive functioning for older adults?

Lee Hyer: The impact of vitamins on cognitive functioning in older adults is still to be determined. Data is generally on health or function and there is some data on the impact of a Mediterranean diet (not vitamins) on cognition. There is some potentially promising work for the impact of CoQ10 for Parkinson’s Disease (PD) but this is largely speculative at this point.

Dr. Hyer mentioned that patients in his clinic are recommended to follow a Mediterranean diet. Is there more information on this diet?

Lee Hyer: Google it and see the diet itself. I am aware of a few studies that show its value on delay of cognitive decline and reduction of health problems. Diabetes seems especially to be impacted by it.

Cogmed: For more information on the Mediterranean diet, it may be valuable to begin your research with the diet description from the National Institute of Health. Click here for more information click here.

Where will the MCI data with Cogmed be available or published?

Cogmed: Dr. Hyer is in the process of writing a book and preparing text that is intended for submission to the American Journal of Geriatric Psychiatry. To contact Dr. Hyer click here.

How helpful is the daily playing of video games among adults 60 -70 years old? If helpful, are video games that require novel and extensive strategies (e.g., first-person shooter games like Halo and World of Warcraft) more helpful than games like Plants vs. Zombies that are more repetitive but increasingly challenging?

Lee Hyer: There is some evidence from a passive controlled study that World of Warcraft has been helpful. Dr. Gary Small also talks of differences in brain activity between “net naïve” and “net savvy” senior citizens. The brain responds well to new tasks – like a computer game that is exciting and challenging. The brain likes novel. But, Owen et al. (2002) say it is too soon to recommend games based on their review of the literature and findings from their own training study. Differently, Valenzuela et al. (2009) recommends cognitive exercise for older adults. The Cochrane Report 77 also explains that cognitive stimulation helps dementing patients on cognitive functioning. In BMC Geriatrics, scientists assessed the effectiveness of two types of cognitive training – repetitive cognitive exercises and training in applied memory exercises with an MCI group. Results suggest that repetitive cognitive exercises that involve practice of specific cognitive abilities (attention and processing speed) are more effective in slowing memory decline than memory strategy training (practice in visualization or mnemonics). The researchers analyzed 10 studies with 305 older subjects and most of these did not involve computers.

Are you aware of Dr. Grace Jackson’s book: Drug Induced Dementia? You highlighted factors that can lead to dementia and prevent dementia but not data relating to the usage of psychiatric drugs. What are your thoughts on psychiatric drugs causing and or exacerbating mild dementia?

Lee Hyer: I do not know of this book, but I know of its hypotheses. Dr. R.J. Caselli also has a good study on the use of psychotropic (CNS) medications and the problems with older adults over time with cognitive decline. This is a real problem with cognitive decline and dementia. Lowenstein notes that older adults who are mentally ill fall off the cognitive charts at age 70 due probably to CNS medications.

What are your thoughts on the efficacy of neurofeedback training for aging adults?

Lee Hyer: I wish I knew. But, my two cents is that it will be as effective as with adults especially with healthy adults who use this in the context of good life habits.

Why should we be excited about offering Cogmed to folks with MCI if there are no major differences between Cogmed and “sham”? This seems to speak to some of the criticisms in Shipstead et al. (2010) about working memory training efficacy versus placebo training.

Lee Hyer: The strict answer is that we cannot be absolute here. But, recall that Cogmed did better than Sham across the board cognitively and was significant in the less cognitive areas. So, Shipstead et al. applies here and we must be circumspect but, the data are seductive in the Cogmed direction. Thanks for asking this question.

What is the difference between Cogmed and Lumosity?

Cogmed: Cogmed does not comment on the approach of other interventions. The efficacy of Cogmed is supported by an evidence base of randomized, controlled studies. Independent researchers around the world have validated Cogmed’s coaching method and computerized working memory training. Further, these studies assess improvements in working memory and other executive functions by using tasks that are distinct from those completed during training. Cogmed cites literature stressing the importance of working memory as it relates to attention and other executive functions and behaviors but, does not cite research of other “brain training” programs as proof that our intervention works. We encourage individuals interested in doing or offering “brain training” to do dig into the literature supporting each intervention and to make an informed decision.

How long is each session when administering Cogmed? Can you explain more about what you mean by “non-adaptive” or “sham” training? What is the “Sham” exercise that was used in the group that was compared to the Cogmed group?

Cogmed: Cogmed Working Memory Training is an adaptive, computerized program with 12 available domain-general working memory exercises. The standard protocol for training involves the user completing 8 of the 12 exercises for 30-40 minutes per day, 5 days per week for 5 weeks. Each exercise includes 15 trials for a total of 120 trials per training day. The program adapts according to individual user performance – becoming increasingly more or less difficult depending on whether a user answers correctly or incorrectly. Task difficulty adjusts not only by increasing or decreasing the number of “to be remembered items” but also, in adjusting the arrangement of items in increasingly or decreasingly more difficult patterns. A Cogmed qualified coach oversees the user as they train, monitoring and supporting them and providing weekly feedback.

In order to counter alternate explanations for the observed training effects after Cogmed (e.g., practice, expectancy, maturation, coach support and attention etc.), researchers include a non-adaptive training control group. Non-adaptive training is also known as placebo or “sham” training and resembles the adaptive training program and protocol in every way except that it does not include individualized adjustment of task difficulty. Instead, task difficulty is fixed at a low level with the user training on 2 or 3 items for the duration. Such low level training is not challenging for most individual’s working memory and so repeated training at this level does not increase capacity. Thus, the sham group is exposed to the same conditions as the Cogmed group – including coach support, rewards, and training environment – but does not effectively train working memory.

How often should or could Cogmed be repeated for students with ADD?

Cogmed: Research on Cogmed for children with ADHD/ADD has revealed that computerized, adaptive working memory training results in increased working memory capacity and attention. Behavioral symptoms have also been seen to decrease in this group after training. This research as well as the clinical use of Cogmed has followed a standard protocol of 30-40 minutes active training time, 5 days per week for 5 weeks. Thus, Cogmed supports use of the standard training protocol for individuals with working memory constraint, including students with ADD. There is currently no research basis for extended or repeated use of Cogmed but, this is an area that of investigation that would be welcomed by Cogmed.